::.:;i73 by The •,;v~lli&_rr,s &
DIAGNOSIS OF A.NTERIOR URETHRAL VALVES F. BRANTLEY SCOTT
From the Roy and Lillie Cullen Department of Urologic Research, Division of Urology, Baylor College of 1\Jedicine, the 1Vficturition Laboratories, St. Luke)s Episcopal and Texas Children)s liospitals and the Urology Service, Texas Children's Hospital, Houston, Texas
We herein describe a , u 1Ju.u~~ method of detecting anterior urethral valves, which may be difficult to demonstrate. In our case some of the conventional methods used to diagnose lower urinary tract problems did not cit first lead to the of an anterior urethral valve. abnormal uroflowmetry caused us to persist in searching for a probable anterior urethral valve. Because of these results a malleable probe is routinely used to test the urethra for possible anterior valve at the time of cystoscopy. In our patient cystoscopy did not reveal the valve even when it was known to be present.
Initial studies consisted of a flow rate, which indicated the presence of obstruction. Excretory as were the findings of voiding showed no evidence of infection. Careful cystoscopy and panendoscopy were entirely normal, no evidence of outlet obstruction. At the time of cystoscopy, passage of the bougie a boule was quite normal with no indication of constriction at 16 French. Since was abnormal and all other findings were normal, it was thought that the might have a neurogenic bladder with detrusor-sphincter dyssynergia or
FIG. 1. A, voiding ur,2thrograrr1 shO'ws d.12:.nge 1n deforrnity. CASE REPORT
white at 'Nhich time diagnosed lower and infection. The infection boy was referred to us.
chills and fever m
the was which included simultaneous measurernent of intravesical pressure, urinary flow rate and eu~c1Tr,mvo•2"f'Brinv of the 1 • 2 The micturition urethral re-
Accepted for publication December 29, 1972.
Scott, F. B., Quesada, E. M. and Cardus, D.: Studies
SCOTT AND CAFFARENA
FIG. 2. A, malleable probe used for detection of anterior urethral valves. B, malleable probe stroking urethra
vealed high bladder pressures but poor urinary flow rates. Although the urodynamic measurements indicated definite obstruction, it was obvious that the sphincter relaxed in a normal manner on the basis of electromyography. Thus, detrusorsphincter dyssynergia was ruled out and neurogenic bladder dysfunction was regarded as highly unlikely. The voiding fluorocystography was repeated, with the radiologist instructed to examine the distal urethra during voiding. This study revealed the presence of an abrupt change in caliber of the urethra immediately distal to the penoscrotal angle (fig. 1, A). The finding was confirmed at repeat cystoscopy by means of a conventional urethrogram with the addition of compression against the proximal bulbous urethra by means of a sponge on a stick. Under these circumstances the distal urethra was of normal caliber and, indeed, the obstruction was a simple cusp valve type of deformity (fig. 1, B). Repeat cystoscopy, even with the knowledge of the valve, failed to disclose the presence of this valve simply because of the limitations of the optical examination at close apposition of the lens against the urethral mucosa. However, a on the dynamics of micturition: observations on healthy men. J. Urol., 92: 455, 1964. 2 Cardus, D., Quesada, E. M. and Scott, F. B.: Use of an electromagnetic flowmeter for urine flow measurements. J. Appl. Physiol., 18: 845, 1963.
small malleable probe was modified by bending the tip sharply against itself to create a small hook (fig. 2). The probe was then used to gently stroke the urethra. It was apparent that stroking between the 5 and 7 o'clock positions of the penile urethra revealed a snagging effect, whereas stroking the anterior portion of the urethra failed to disclose any impairment in the movement of the probe. Transurethral resection couid not be done since the valve could not be seen cystoscopically. At the time of open resection, the probe was again used to identify the exact position of the valve, so that the incision could be made directly over the cusp of the valve. Convalescence was uneventful and postoperative voiding flow rates were entirely normal, with peak values of 18 cc per second. DISCUSSION
There are only 12 cases of anterior urethral valves reported in the literature. 3- 7 An important 'Waterhouse, K. and Scordamaglia, L. J.: Anterior urethral valve: a rare cause of bilateral hydronephrosis. J. Urol., 87: 556, 1962. •Chang, C-Y.: Anterior urethral valves: a case report. J. Urol., 100: 29, 1968. 5 Colabawalla, B. N.: Anterior urethral valve: a case report. J. Urol., 94: 58, 1965. • Sawanishi, K.: Congenital valve of anterior urethra in infant; report of a case. Acta Urol. Jap., 8: 419, 1962. 7 Texter, J. H. and Engel, R. M. E.: Anterior urethral valve as cause for urinary obstruction: a case report. J. Urol., 107: 316, 1972.
observation i:n our case 1.;vas that V!&S abnormal and indicated lower tract obstruction. The initiai rocystograrn was normal because the had not examined the entire urethra. The mictmishowed the presence of lower obstruction without any evidence of VVe now use a
rnalleable a be!1d in the the tirfl.e of cystoscopy in order to eli1r1inate the possiof anterior t1rethral valves i:n a child v,lith poor flow. This method effective and is forn1. tions.